Health

Summary

Mr C complained about the psychiatric care andtreatment he received from the board, specifically that he disagreed with thediagnosis given to him and also that prescribed medication had caused unwanted psychological and physical problems . Mr C also had concerns that his medical recordsdid not hold an accurate account of his views in relation to his treatment anddiagnosis. We found his records did hold this information. We tookadvice from a psychiatric adviser and found that the care and treatmentprovided to Mr C had been appropriate and reasonable. We did not uphold Mr C'scomplaint.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) at Borders General Hospital. Mr A had a long history of health problems including arthritis (a disease causing painfulinflammation and stiffness of the joints) and chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) and he was admitted to hospital due to the severity of his tremors. Mr A had been taking regular doses of dihydrocodeine (DHC, an opioid painkiller) for several years for his arthritic pain. When he was admitted to hospital, Mr A's DHC was stopped and he suffered withdrawal symptoms. Mrs C complained that Mr A's medication was stopped for no reason. The board explained that there was no signature on the drug chart so they could not identify who stopped the medication and why but they had taken steps to address this failing.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the decision to stop the DHC was likely an error and we were satisfied the board had taken the appropriate steps to remind all junior doctors of the importance of documenting their decisions in the clinical notes. We upheld the complaint on the basis that it could not be identified why the medication was stopped and made a further recommendation in relation to complaint handling.

Mrs C also complained that Mr A was discharged from hospital when he was still very ill and that there was little consultation with the family and consideration of how they would manage at home. The board confirmed that Mr A was clinically well enough to be discharged home and that they delayed the discharge appropriately when Mr A's wife expressed concerns about how she would cope at home. We found that Mr A was medically fit for discharge and the process was appropriately managed. We did not uphold the complaint.

Recommendations

In relation to complaints handling, we recommended:

• Reasonable steps should be taken in future to identify relevant parties involved in complaint issues, to allow the issues to be thoroughly investigated, responded to in specific terms, and focussed learning to take place. This should be highlighted to all complaints handling staff.

Summary

Mrs C complained about the care of her late father (Mr A) at University Hospital Ayr. Mr A underwent surgery to remove bowel cancer and required further surgery due to a complication. He remained unwell thereafter and, due to his poor nutrition and weight loss, a decision was made to start nasogastric (NG) tube feeding (where a tube is placed through the nose into the stomach). However, the NG tube was mistakenly inserted into Mr A’s lungs instead of his stomach and this was not recognised prior to commencement of NG feeding. This error caused a severe deterioration in Mr A’s condition and he died just over a week later. The board carried out a Significant Adverse Event Review (SAER) and the Crown Office and Procurator Fiscal Service (COPFS) also looked into the circumstances of the death. As Mrs C was unhappy with the outcome of the board’s SAER and response to her subsequent complaint, she contacted the SPSO.

We took independent advice from a consultant gastroenterologist (a physician who specialises inthe diagnosis and treatment of disorders of the stomach and intestines)(a physician who specialises inthe diagnosis and treatment of disorders of the stomach and intestines). We considered that the board’s SAER process was reasonable and recommended appropriate policy changes to prevent a similar future recurrence. It was identified that there were some departures from existing policy but these did not contribute to Mr A’s death. These included record-keeping deficiencies and a failure to take all advised steps to obtain an aspirate (where a small amount of stomach content is sucked through the tube and the acidity checked to confirm correct placement of the tube). As the tube was incorrectly placed in this case, the further advised steps would have been unsuccessful anyway and an x-ray would still have been required. The significant failing was a consultant surgeon’s incorrect interpretation of the x-ray and consequent failure to identify the misplacement of the NG tube. This misinterpretation occurred out-of-hours when the consultant was in theatre preparing for surgery. The new policy position is that NG feeding will not be commenced overnight, and will only commence after a consultant radiologist has reviewed the x-ray and confirmed the correct placement of the tube.

We raised concerns that the board issued an initial death certificate which failed to record that Mr A died of aspiration pneumonia due to a misplaced NG feeding tube, when this was quite clear. COPFS subsequently amended the cause of death to include ‘misplaced NG tube and NG feed’. We upheld this complaint. While we were satisfied that appropriate steps had been taken to address the significant failing which contributed to Mr A’s death, we made some recommendations for the board to take additional steps.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the failure to issue a death certificate accurately recording that he died of aspiration pneumonia due to a misplaced NG feeding tube. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets

What we said should change to put things right in future:

• The board should remind relevant medical staff that, when issuing a death certificate, careful consideration needs to be given to ensuring it accurately reflects the cause and circumstances of the death, regardless of how that might be viewed or interpreted.
• The board should inform the Ombudsman what steps were taken following the SAER, or what steps they intend to take now, to ensure future adherence to local policy regarding obtaining an aspirate and keeping records of the NG tube insertion process.

Summary

Ms C complained on behalf of her father (Mr A) that it was unreasonable for the practice to refuse Mr A a home visit. Mr A had been seen by the practice the day before and the next day a home visit was requested for him. The practice did not consider that a home visit was required and asked Mr A to attend, which he agreed to. Ms C said that Mr A required urgent medical attention and should have been seen at home.

We took independent medical advice and found that whilst there were differing accounts of what was discussed during the call requesting a home visit, there was no evidence in the medical records of clinical symptoms which were described during the call, nor in the notes from Mr A's appointment the previous day, which would have suggested a house call was required. We found that the practice's policy on home visits was reasonable and was applied appropriately in the circumstances. Therefore, we did not uphold this aspect of the complaint.

Ms C also complained that the practice's response to her complaint was unreasonable. We found that the practice failed to communicate with Ms C in line with their complaints handling procedure. Therefore, we upheld this aspect of the complaint. We noted that the practice had apologised for this but made a further recommendation for learning and improvement.

Recommendations

In relation to complaints handling, we recommended:

• All staff who handle complaints should be made aware of the findings of our investigation and reminded of the requirements of the complaints handling procedure.

Summary

Mr C, a patient advocate, complained on behalf of his client (Mrs B) about Western Isles Hospital. Mrs B was unhappy with the care provided to her mother (Mrs A) who was admitted to the hospital and received treatment for sepsis (a blood infection). Mrs A's condition significantly deteriorated in the weeks following admission. She was then transferred to a hospital in Glasgow, where she died from her illness.

In response to the complaint, the board identified learning and improvement in relation to communication and nursing monitoring records.

Mr C complained about the care and treatment provided to Mrs A during the admission and that there was a delay in transferring her when her condition deteriorated.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment ofdiseases and injuries of the musculoskeletal system) and from a registered nurse. We found that medical staff managed Mrs A's condition in a reasonable manner. In particular, there were regular reviews, reasonable investigations were arranged and treatment was responsive to her condition. We did not identify any delay in the board transferring Mrs A when her condition deteriorated. We also found that the nursing care provided was reasonable. We noted that there was evidence of appropriate care planning, monitoring and interventions. We did not uphold these aspects of the complaint.

Finally, Mr C complained that the board did not communicate reasonably with Mrs B about Mrs A's care. The board upheld this complaint and outlined improvement work. We were satisfied that the board had taken appropriate action. We upheld this complaint but made no recommendations.

Summary

Mr C complained about the care and treatment he received at Ninewells Hospital after he ruptured his Achilles tendon. After he was reviewed by a consultant, conservative (non-operative) treatment of his injury was initiated. After a number of reviews, Mr C was discharged. He requested a further review as he was concerned about the progress of his recovery but no further action was taken following this review.

Months after his initial injury, Mr C re-ruptured his Achilles tendon. He was reviewed the following day and it was decided that surgery was necessary. There was a delay in surgery taking place, partly due to the surgeon being on annual leave. When Mr C attended the hospital to receive surgery, he remained on the ward all day before being told in the evening that surgery would not be required. He then underwent surgery two days later.

Mr C complained to us about the care and treatment he received for his initial injury, including the fact that he did not receive physiotherapy after his cast was removed. He also complained about what he considered to be unreasonable delays and communication after he re-ruptured his Achilles tendon.

We took independent advice from an adviser with a background as a trauma and orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the board had failed to provide reasonable or appropriate care and treatment to Mr C following his initial injury. Although conservative treatment was appropriate for this kind of injury, we did not consider that other treatment options were fully discussed with Mr C. In addition to this, we concluded that it was unreasonable for an appropriate form of physiotherapy not to be suggested or discussed with Mr C. We highlighted that there was no evidence to suggest that this contributed to Mr C re-rupturing his Achilles tendon. However, we concluded that there were failings in Mr C's care and treatment that had had a negative impact on his patient journey. Therefore, we upheld this aspect of the complaint.

In respect of the complaint about delays and communication, we found that the timescale for Mr C receiving surgery was reasonable. However, we considered that the internal communication and communication with Mr C on the day he was initially due to receive surgery was unreasonable. The records show that he remained on the ward, while fasting, from early in the morning until the evening. However, at some point during the day, his surgery was cancelled due to there being more urgent emergency cases. This information was not relayed to staff on the ward, despite them making enquiries. We did not consider the fact that the surgery was cancelled to be unreasonable, as it is understandable that emergency cases may have to take priority at short notice. However, when it was known that the surgery was cancelled, this should have been relayed to the ward as soon as possible. The fact that this did not happen resulted in further frustration and anxiety for Mr C. As a result of this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably failing to fully discuss treatment options with him, discharging him without discussing physiotherapy or a home exercise programme and for keeping him in hospital despite the fact that the surgery had been cancelled earlier that day. The apology should meet the standards setout in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Where appropriate, a range of treatment options should be openly discussed with the patient and a shared decision-making approach taken.
• The board should reflect on what happened and ensure that appropriate follow-up actions are considered when a patient is discharged following an Achilles tendon rupture. This includes discussing relevant physiotherapy and home exercise options with the patient.
• Reflect on how this situation happened and consider whether there are any improvements that can be put in place to help prevent a similar situation from occurring again.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained on behalf of her late relative (Mrs A) about the information given to Mrs A by doctors prior to her death in hospital. Mrs C was unhappy that Mrs A was told that she was dying, and that she was asked where she wanted to be when she died. We found that on one occasion Mrs A asked for information about her prognosis and she was provided with an honest response. We also found there was evidence of a further discussion with Mrs A regarding her future care when it was disclosed to her that she was dying. The General Medical Council (GMC) guidance states that a doctor must answer patients' questions honestly. It also states that information necessary for making decisions should not be withheld even if another relative asks the doctor to do this, unless the doctor considers that this would cause the patient serious harm. It was recorded that Mrs A had capacity and that she required to be involved in discussions about her future care. We found that the doctors were required to make Mrs A aware of her situation in order to obtain her consent. We did not uphold this aspect of the complaint.

Mrs C also complained about a failure to address her complaint about an item of hers that went missing in the hospital. We did not uphold this complaint on the basis that the board had initially logged the complaint. Although the board delayed in addressing the complaint they proceeded to apologise for the fact that it had not it had been addressed sooner.

Summary

Ms C complained about the way in which the board handled her complaint and what she considered to be inaccurate information in their response. Ms C highlighted a section of the response where the board detailed two tests they claimed were previously carried out. Ms C stated that these tests did not, in fact, take place. We reviewed the relevant medical records and were satisfied it was reasonable for the board to state that one of the tests took place. However, there was no evidence of the other test taking place and we concluded that the evidence provided by Ms C supported her account of cancelling the appointment for this test before it took place. It was not clear to us why this inaccurate information was included in the board's response, along with a statement that the results were normal. Therefore, we upheld this aspect of the complaint.

Ms C also complained that the board's response contained inaccurate information about whether she had been diagnosed with a type of anaemia (a condition in which there is a deficiency of red cells in the blood). We found that Ms C had previously received the diagnosis. The diagnosis was subsequently questioned by other medical professionals. However, there was no evidence to confirm that this had ever been fully clarified to Ms C. Furthermore, the medical records show that the initial diagnosis, whether correct or not, continued to inform subsequent consultations. In light of this, we upheld this aspect of the complaint.

Finally, Ms C complained about the board's failure to respond to her correspondence within an appropriate timescale. We considered her complaint itself to have been handled appropriately. However, we considered the board's handling of her post-complaint correspondence to be unreasonable. Although we considered that the board's complaint and feedback team were not the most appropriate place for Ms C to direct some of her enquiries, it still would have been reasonable to expect the board to respond in a clear and timely fashion. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for providing inaccurate information in their stage two response about a test being carried out; providing an inaccurate or incomplete account of Ms C's diagnosis history in relation to pernicious anaemia in their stage two response; and for failing to respond to Ms C's correspondence within an appropriate timescale after they issued their stage two response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide clarification, as far as is possible, about whether or not Ms C's symptoms and test results support a diagnosis of pernicious anaemia. If necessary, carry out appropriate tests to allow such clarification to be provided.

In relation to complaints handling, we recommended:

• Stage two complaint responses should contain accurate information and establish all the facts relevant to the points made in the complaint. The board should explore how and why the stage two response contained inaccurate information.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained that the board failed to diagnose a ruptured Achilles tendon when she attended Western General Hospital. We took independent advice from a consultant physician in acute internal medicine. We found that given the specific test for excluding a ruptured Achilles tendon was carried out, which resulted in a negative finding, it was reasonable that the ruptured Achilles tendon was not diagnosed. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the care and treatment she received at the Edinburgh Royal Infirmary after the ruptured Achilles tendon had been diagnosed. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the care and treatment provided to Ms C was reasonable and did not uphold this aspect of her complaint.

Ms C complained that the board failed to communicate reasonably with her. We found that there was no record of any detailed discussion with Ms C prior to her surgeries about the risks or benefits of the proposed operations, the alternatives to surgery or the varying degrees of success and the possibility that her condition could be made worse. The board had a document for recording fasting and insulin instructions for diabetic patients but this was not completed in Ms C's case. Therefore, we upheld Ms C's complaint that the board's communication with her was unreasonable.

Ms C complained about the way that that the board handled her complaint. We found that Ms C's complaint was not acknowledged within three working days. There was also a delay in responding to Ms C's complaint and the board did not proactively keep her updated about the reason for the delay in responding to her complaint and provide a revised timescale for when she could expect to receive a response. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to record a detailed discussion with her prior to her surgeries about the risk or benefits of the proposed operations, failing to acknowledge Ms C's complaint within three working days and for failing to keep her updated about the reason for the delay in responding to the complaint or providing a revised timescale for the response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients should be given full information about the risks and benefits of proposed operations, including the alternatives to surgery, and these discussions should be documented in line with relevant guidance.
• Diabetic patients should be given fasting and/or insulin instructions prior to surgery and these instructions should be recorded.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.